Uptake of Active Surveillance for Very-Low-Risk Prostate Cancer in Sweden

Abstract

Importance: Active surveillance is an important option to reduce prostate cancer overtreatment, but it remains underutilized in many countries. Models from the United States show that greater use of active surveillance is important for prostate cancer screening to be cost-effective.

Objectives: To perform an up-to-date, nationwide, population-based study on use of active surveillance for localized prostate cancer in Sweden.

Design, setting, and participants: Cross-sectional study in the National Prostate Cancer Register (NPCR) of Sweden from 2009 through 2014. The NPCR has data on 98% of prostate cancers diagnosed in Sweden and has comprehensive linkages to other nationwide databases. Overall, 32 518 men with a median age of 67 years were diagnosed with favorable-risk prostate cancer, including 4693, 15 403, and 17 115 men with very-low-risk (subset of the low-risk group) (clinical stage, T1c; Gleason score, ≤6; prostate-specific antigen [PSA], <10 ng/mL; PSA density <0.15 ng/mL/cm3; and <8-mm total cancer length in ≤4 positive biopsy cores), low-risk (including all men in the very-low-risk group) (T1-T2; Gleason score, ≤6; and PSA, <10 ng/mL), and intermediate-risk disease (T1-T2 with Gleason score, 7 and/or PSA, 10-20 ng/mL).

Exposures: Diagnosis with favorable-risk prostate cancer.

Main outcomes and measures: Utilization of active surveillance.

Results: The use of active surveillance increased in men of all ages from 57% (380 of 665) to 91% (939 of 1027) for very-low-risk prostate cancer and from 40% (1159 of 2895) to 74% (1951 of 2644) for low-risk prostate cancer, with the strongest increase occurring from 2011 onward. Among men aged 50 to 59 years, 88% (211 of 240) with very-low-risk and 68% (351 of 518) with low-risk disease chose active surveillance in 2014. Use of active surveillance for intermediate-risk disease remained lower, 19% (561 of 3030) in 2014.

Conclusions and relevance: Active surveillance has become the dominant management for low-risk prostate cancer among men in Sweden, with the highest rates yet reported and almost complete uptake for very-low-risk cancer. These data should serve as a benchmark to compare the use of active surveillance for favorable-risk disease around the world.

Figure

Use of active surveillance (AS) and watchful waiting (WW) in Sweden from 2009–2014. Results are shown by age group and clinical risk category: very low-risk (clinical stage T1c, Gleason score ≤6, PSA <10 ng/ml, PSA density <0.15ng/ml/cm³, <8mm total cancer length in ≤4 positive biopsy cores)[8], low-risk (T1–T2, Gleason score ≤6 and PSA <10ng/ml), and intermediate-risk (T1–T2 with Gleason score 7 and/or PSA 10–20ng/ml).